Imaging of Aortic and
B r a n c h Ve s s e l Tr a u m a
Martin L. Gunn, MBChB, FRANZCR
KEYWORDS
 Aortic injury  Multidetector-row computed tomography
 Trauma
Although infrequently encountered even in busy
trauma centers, injuries to the aorta and branch
vessels remain an important cause of trauma-
related mortality.1 Advances in the diagnosis and
management of these injuries have led to more
accurate and timely imaging, and improved patient
outcomes.2 Thoracic multidetector-row computed
tomography (MDCT) has now supplanted catheter
angiography as the reference standard for the
diagnosis of thoracic aortic injury, and endo-
vascular repair has reduced mortality. Delays in
evaluating the aorta have been reduced with im-
plementation of rapid multiregional computed
tomography (CT) in the severely injured patient,
and previously unrecognized minor aortic injuries
are now increasingly apparent.3–5
Despite these advances, several challenges in
evaluating the severely injured trauma patient
remain. Although liberal use of MDCT will result
in the diagnosis of nearly all blunt aortic injuries,
effective clinical prediction rules to determine the
exact indications for CT have not yet been devel-
oped.6 This drawback is of particular concern, as
radiation exposure from radiographs and CT is
high in multitrauma patients and health care costs
of imaging are rising.7,8 Moreover, some findings
on CT can be challenging to interpret, and in
some cases require further imaging.9 This review
provides an overview of current concepts in the
imaging of aortic and branch vessel injuries, and
provides pointers to improve detection and inter-
pretation of more challenging cases.
NORMAL AORTIC ANATOMY
The thoracic aorta can be divided into anatomic
segments. The aortic root is a short segment of
Disclosures: No funding support provided for this project, or relevant disclosures.
Department of Radiology, University of Washington, 325 9th Avenue, Box 359728, Seattle, WA 98104, USA
E-mail address: marting@uw.edu
Radiol Clin N Am 50 (2012) 85–103
doi:10.1016/j.rcl.2011.08.002
0033-8389/12/$ – see front matter Ó 2012 Elsevier Inc. All rights reserved.
the aorta arising from the heart, and contains the
aortic valve, aortic annulus, and coronary sinuses.
The aortic root and proximal ascending aorta is
surrounded by the superior aortic recess of the
pericardium. This recess is a cranial extension of
the transverse pericardial sinus and is composed
of anterior, right lateral, and posterior portions. It
can usually be seen on CT.10 The ascending aorta
extends from the root to the proximal edge of the
brachiocephalic artery. The aortic arch continues
from brachiocephalic artery to the attachment of
the ligamentum arteriosum and gives rise to the
brachiocephalic artery, left common carotid, and
left subclavian arteries. The descending thoracic
aorta is the segment between the ligamentum ar-
teriosum and the aortic hiatus of the diaphragm.
The portion of the descending aorta between left
subclavian artery and the ligamentum arteriosum
is termed the aortic isthmus.
Variants in arch anatomy are common. In 13%
of patients there is a common origin of the brachio-
cephalic and left common carotid arteries; the
so-called bovine-arch.11 In 6% of cases, the left
vertebral artery has an aortic origin.12
EPIDEMIOLOGY, OUTCOME, AND
PATHOPHYSIOLOGY
Blunt thoracic aortic injury (BTAI) is a highly lethal
injury. Although aortic injuries occur in less than
0.5% to 2% of nonlethal motor vehicle collisions
(MVCs), it has been found in up to 34% of trauma
fatalities at autopsy.1,13,14 Up to 80% of patients
die from aortic injury at the scene. The incidence
of aortic injury associated with MVCs does not
radiologic.theclinics.com
appear to be declining, although the patterns
of vehicular intrusion have been changing from
86 Gunn
frontal impact to side (especially near-side)
impact.14–16 Other causes of aortic injury include
motorcycle and aircraft crashes, pedestrian in-
juries, falls from height, and crush injuries.
BTAI has traditionally been considered a surgical
emergency, based largely on the work of Parmley
in the 1950s, when there was a 1% mortality rate
per hour in the first 48 hours of hospitalization.17
Following the widespread implementation of early
blood pressure control for aortic injury, a different
mortality pattern has emerged over the last several
years. Patients arriving in the emergency depart-
ment in extremis still have a very high probability
of death, approaching 100%.18 However, patients
who arrive hemodynamically stable and are man-
aged with b-blockade and definitive repair do
considerably better, even with “delayed” repair.
Between the first American Association for the
Surgery of Trauma trial (AAST1) in 1997 and the
second trial in 2007 (AAST2), there was a significant
reduction in both mortality and morbidity from
blunt aortic injury.2,18 Over this period, the short-
term mortality (excluding patients who arrive in
extremis) improved from 22% to 13%, and the
paraplegia rate fell from 8.7% to 1.6%. There are
multiple reasons for this mortality reduction. Over
this period, CT scanning virtually replaced catheter
aortography and transesophageal echocardiog-
raphy (TEE) as the primary diagnostic test. In addi-
tion, the time from admission to definitive repair
increased, and the means of repair switched
from exclusively open repair to predominantly en-
dovascular repair. Although recent short and
medium term outcome studies are very promising,
outcome studies evaluating the long-term out-
come of endovascular repair, especially in young
patients, are awaited.
Despite several proposed pathophysiological
mechanisms for blunt aortic injury, the exact
mechanism has not been determined. In reality,
a combination of mechanisms likely accounts for
the spectrum of injuries that are encountered.
The deceleration shear force theory proposes
that shearing forces are generated in the aorta
at points of differential deceleration. During rapid
deceleration, fixation of the aorta by the great
vessels, heart, and ligamentum arteriosum cause
shearing injuries where these points intersect
with more mobile sections of the aorta. This theory
accounts for the tendency of aortic injuries to
occur adjacent to the aortic isthmus, and for the
incidence of aortic injuries correlating with decel-
eration of more than 20 mph (32 km/h) and vehic-
ular intrusion.19,20 The “osseous pinch” theory
hypothesizes that rupture of the aorta is due to
entrapment of the aorta between the anterior
thoracic bony structures (manubrium, clavicle,
and first ribs) and the vertebral column, resulting
in transverse lacerations at the aortic isthmus.21
This mechanism may also explain concomitant
injuries to some branch vessels.13 The water-
hammer theory proposes that sudden increased
intravascular pressure from aortic occlusion at
the diaphragm results in transmission of a signifi-
cant pressure pulse to the aortic arch, resulting
in transverse tears in the aortic arch at the level
of the isthmus, which is the weakest point.22,23
In autopsy series, 58% to 90% of thoracic
aortic injuries occur at the level of the aortic
isthmus.14,17,24,25 The next most common region,
the aortic root and ascending aorta, comprises
5% to 10% of aortic injuries. Injury to the aortic
root and ascending aorta is usually immediately
fatal, and clinical presentation is extremely
rare.25 Between 3% and 8% of injuries occur in
the distal descending thoracic aorta.24 Five to
seventeen percent of aortic injuries occur at
branch vessel origins.26,27 Aortic injuries are multi-
focal in 13% to 18% of patients.14,24,25
Blunt abdominal aortic injuries (BAAI) represent
only about 5% of blunt aortic injuries.28 BAAI are
associated with high-speed MVCs, and have
been linked to steering-wheel injury to the lower
abdomen and the use of lap-belt restraints.28 Like
BTAI, the mechanism of injury is unclear, but theo-
ries include direct compression of the aorta against
the spine, stretching of the aortic wall by elevation
of the intraluminal pressure following sudden
compression, differential shearing forces at the
aortic bifurcation, and longitudinal aortic stretch-
ing accompanying distraction injuries of the
lumbar spine.29,30 As with BTAI, there has been
a recent shift to endovascular repair of BAAI, with
good short-term outcomes.28–30 Endovascular
repair avoids the potential for surgical graft infec-
tion from concurrent bowel injury. Surgical treat-
ment is associated with an overall mortality of 27%.
Penetrating aortic injury represents 14% of
aortic injuries at autopsy. These injuries are almost
always attributable to knife and gunshot injuries.25
Rare causes include misplacement of spinal fixa-
tion screws, and lacerations from spinal frac-
tures.31 Gunshot injuries to the thoracic aorta
have a strong predilection for the ascending aorta.
Stab wounds are strongly associated with branch
vessel injuries.25 Most patients who arrive alive at
the hospital with penetrating aortic injuries will
have injuries to the abdominal aorta rather than
the thoracic aorta.32 Patients often arrive at the
hospital in hypovolemic shock. The outcome of
penetrating aortic injuries is usually dismal, with
thoracic aortic injuries faring worse than abdom-
inal aortic injuries (92% vs 76% mortality). 32 En-
dovascular repair has been described.33
 Imaging of Aortic and Branch Vessel Trauma 87

CLASSIFICATION OF AORTIC INJURY first-rib fractures in both children and adults. In

Over the years, classification systems for BTAI
have been developed based on time course, patho-
logic appearance, and imaging appearance.34–36
For the radiologist and vascular surgeon, the best
classification system to guide management may
be one based on imaging appearances, proposed
by Azizzadeh and colleagues34 in 2009 (Fig. 1).
This system is valuable because it includes
minimal aortic injuries, which are increasingly
identified with the use of screening CT.4
ASSOCIATED INJURIES
Associated injuries can provide clues to the pres-
ence of an aortic injury. Historically first rib frac-
tures, which are associated with high-energy
injury trauma, have been considered to be strongly
associated with aortic and great vessel injuries.
However, recent evidence suggests that angiog-
raphy is not indicated solely by the presence of
a series by Hamilton and colleagues,37 none of
the 22 pediatric patients with a first-rib fracture
and a normal mediastinum on plain radiography
had a traumatic vascular injury on CT or clinical
follow-up. Although there does appear to be an
association between vascular injuries and frac-
tures of the upper ribs, the conclusion of multiple
series is that decision to perform angiography
should not be based solely on the presence of
a first-rib fracture, but on clinical signs of vascular
injury and/or an abnormal mediastinum.38
Commonly identified on chest CT, first-rib and
second-rib fractures were present in almost half
of the trauma CTs performed in one series. These
investigators found similar rates of aortic and great
vessel injury in patients with and without first-rib or
second-rib fractures.39
In a recent autopsy study by Teixeria and
colleagues,14 the extent and distribution of asso-
ciated injuries was well documented. These

Fig. 1. Classification of traumatic aortic injury. Grades I and II are considered minimal aortic injuries, and are
treated conservatively when small. Grade III injuries are the most common to present clinically. Survival from
Grade IV injuries is rare. (From Azizzadeh A, Keyhani K, Miller CC III, et al. Blunt traumatic aortic injury: initial
experience with endovascular repair. J Vasc Surg 2009;49(6):1403–8; with permission.)
88 Gunn

investigators found extrathoracic injuries in 96% of Computed Tomography

patients with BTAI. Almost all these injuries are
Multidetector CT angiography (CTA) is the
associated with a high energy mechanism of
reference-standard imaging study for the
trauma. Patients with BTAI are significantly more
diagnosis of blunt traumatic aortic injury.2,47–50
likely than trauma patients without BTAI to have
Accordingly, it has almost completely replaced
cardiac injury, diaphragmatic lacerations, he-
catheter aortography and TEE.2 Indications for
mothorax, rib fractures, pelvic fractures, and
chest CTA include an abnormal aortic contour
intra-abdominal injuries. Sternal fractures and
on plain radiography, clinical signs, and injury
head injuries were not associated with BTAI.14
mechanism suggestive of aortic injury. Several
Posterior sternoclavicular dislocation has been
series have shown that helical CTA has a sensi-
associated with injuries to aortic branch vessels.
tivity of 95% or more for the detection of
BTAI.50–53 In the early days of helical CT for aortic
IMAGING TECHNIQUES injury, reliance of mediastinal hematoma as an
Plain Radiography indirect sign led to a lower reported specificity
for aortic injury, and reliance on catheter angiog-
Chest radiography, specifically the supine chest
raphy as the reference standard. However, as is
radiograph, has long been used as the initial
described later, the finding of isolated mediastinal
means of screening for thoracic aortic injury.
hematoma does not warrant further investigation
However, the chest radiograph may be normal in
following a high-quality MDCT examination.
7% to 11% of cases of acute aortic injury
Unfortunately, CT is not fail-safe. CT artifacts,
(Fig. 2).40–42 Although it has greater specificity,43
variants in the aorta, and subtle aortic injuries
an erect chest radiograph often cannot be ob-
can still be challenging even for the experienced
tained in unstable trauma patients and in the
radiologist.
setting of potential spine injury. A “widened medi-
At most trauma centers, CTA of the thorax in
astinum” is the best known sign of aortic injury.44
patients at risk of BTAI is not performed as
However, the definition of a widened mediastinum
a sole examination. Rather, it is usually integrated
varies. Quantitatively, it refers to a mediastinal
into a whole-body CT (the so-called trauma pan-
width of 8 cm at the level of the aortic arch on
scan), a technique that has been shown to improve
a supine (or erect) chest anteroposterior radio-
survival and reduce imaging time.3,5 There is now
graph.43 Due to variation in patient size, a medias-
the potential to use electrocardiographic (ECG)
tinum to chest-width ratio of (>0.25 [and >0.38])
cardiac gating for the assessment of aortic injury.
has been suggested as a more accurate
Due to its higher temporal resolution, dual-
measure.2,43,45 However, a subjective assessment
source CT (DSCT) ECG-gated (or nongated) CTA
of mediastinal width is usually used in practice.
can be performed without b-blockade in patients
Due to several potential causes of mediastinal
with regular heart rates, and can achieve accept-
widening on a supine radiograph (eg, mediastinal
able motion suppression at radiation doses below
lipomatosis, vascular ectasia or engorgement, atel-
5 mSv.20,54,55 Hence, it is now technically feasible
ectasis), other signs of aortic contour abnormality
to perform ECG-gated CTA as a screening tool for
are usually used to increase specificity (Box 1).
aortic injury. In cases of indeterminate nongated
One technique to improve visualization of the
aortic CTAs, a follow-up gated CTA using single-
aortic contour in supine patients is a coned medi-
source scanners and b-blockade also offers
astinal view with craniocaudal tilt, although routine
promise.
use has not been systemically validated. This view
has been termed the reverse Trendelenburg radio-
Transesophageal Echocardiography
graph.46 As a Trendelenburg position is usually
impractical in the acutely ill patient, at the author’s TEE has sensitivity for the diagnosis of BTAI in the
institution a coned view of the mediastinum is per- 56% to 99% range, with specificity in the 89% to
formed with higher tube potential and 15 of cra- 99% range.56 With the increased use of screening
niocaudal tilt whenever an aortic or mediastinal helical CTA, it is now rarely used; only 1% of BTAI
contour abnormality is suspected on a supine cases were diagnosed with TEE in the AAST2 trial.2
radiograph. Potential reasons for this include lack of avail-
Due to the imperfect sensitivity and poor speci- ability, the need for sedation, and concerns about
ficity of chest radiography, further imaging (almost potential suboptimal sensitivity. TEE does have
always with CT) should be performed whenever an a “blind spot” in the distal ascending aorta and
abnormality is suspected on chest radiography, or proximal branch vessels. TEE can be useful as
when the mechanism of injury is compatible with a diagnostic tool for the evaluation of equivocal
aortic injury. CTA or catheter aortogram.57
 Imaging of Aortic and Branch Vessel Trauma 89

Fig. 2. (A) Mediastinal contour on chest radiography. Mediastinal widening with loss of the aortopulmonary
window, right paratracheal stripe thickening, left apical pleural cap, loss of the descending aortic contour, and
widening of the paravertebral stripe. (B) Thin-slab maximum-intensity projection from a chest CTA shows an
aortic transection with a pseudoaneurysm at the level of the aortic isthmus. (C) Chest radiograph initially re-
ported as negative for aortic injury. Although the mediastinum does not appear widened, there is thickening
of the left paravertebral stripe (arrow) and a left pleural cap. (D) Chest CTA revealed a large pseudoaneurysm
in the aortic isthmus (asterisk), which was successfully managed with endovascular repair.
90 Gunn
Box 1
Radiographic signs of blunt thoracic
aortic injury
Widened mediastinum
Loss of the aortopulmonary window
Loss of definition of the descending thoracic
aorta
Widened right paratracheal stripe
Tracheal shift to the right of the T4 spinous
process
Left main stem bronchus depression
Nasogastric tube displaced to the right
Widened paraspinal stripe
Left apical pleural capa sign
a
A left pleural cap almost never occurs as the
only radiographic sign of a BTAI.
Intravascular Ultrasonography
Intravascular ultrasonography (IVUS) is performed
by introducing a high-frequency (approximately 10
MHz) miniature ultrasound transducer through
a large arterial sheath (approximately 8F) and
obtaining real-time 360 images of the aorta.
Although limited by the absence of a reference-
standard technique, a recent study found that
IVUS performed better than catheter aortography
in patients who had equivocal CTAs.9 The high
cost of the disposable transducers, invasive
nature, and operating room time limit IVUS to
a problem-solving tool at present.
Catheter Aortography
Catheter aortography was long considered to be
the reference-standard examination for the diag-
nosis of aortic injury, with previously reported
sensitivity, specificity, and accuracy all approach-
ing 100%. However, studies were usually limited
by the absence of another test. It does appear
that false-positive catheter angiograms do occur,
particularly in the setting of an atypical ductus
arteriosus.58 Moreover, there is significant interob-
server variability in the interpretation of catheter
angiograms in equivocal cases, greater than that
of IVUS.9,59 Furthermore, since CTA use became
widespread, it has been recognized that minimal
injuries such as intimal tears comprise up to 10%
of BTAI, and most of these are occult on catheter
aortography (Fig. 3).4 The role of catheter aortog-
raphy in the initial diagnosis of BTAI is now limited;
it can be performed without significant delay or
risk of morbidity following pelvic angioemboliza-
tion, but in most cases the assessment for aortic
injury is better performed using CTA integrated
with MDCT of other body regions. Moreover, cath-
eter angiography may have a limited role as
a problem-solving tool in the equivocal CTA, for
which IVUS, or even follow-up gated CTA, are
better options.9
Imaging Algorithm
A recent systematic review of 10 studies to eval-
uate predictors for blunt aortic injuries found that
clinical and radiographic predictors of BTAI did
not perform adequately enough to safely omit
chest CT.6 Consequently, the liberal use of CT
was recommended; this corresponds with the
author’s clinical experience at a high-volume
trauma center. The imaging algorithm performed
at Harborview Medical Center for the assessment
of BTAI is shown in Fig. 4. This algorithm has not
been prospectively tested, although it was shown
to be effective retrospectively.60 Patients who
undergo CTA of the chest for potential aortic injury
usually visit the emergency CT scanner for other
investigations, particularly CT of the head, cervical
spine, and abdomen/pelvis. In these patients, CTA
or CT of the chest is performed as part of a single
helical acquisition, without significantly greater
radiation dose or additional contrast exposure.
IMAGING APPEARANCES OF AORTIC INJURY
Blunt Thoracic Aortic Transection:
Pseudoaneurysm and Rupture
Radiographic signs of BTAI are largely confined to
the detection of mediastinal hematoma, and are
discussed in some detail in earlier sections.
Historically, signs of blunt traumatic injury on CT
of the chest have been classified as indirect and
direct (Box 2). The principal indirect sign of aortic
injury visible on CT of the chest is periaortic hema-
toma.61 Periaortic hematoma usually does not
arise directly from exsanguination of blood from
the aorta, but from injury to small mediastinal
vessels or fractures of the spine or thoracic
cage. The importance of periaortic and perivascu-
lar mediastinal hematoma is that it is a marker of
mediastinal injury, and it should prompt an
extremely careful evaluation for direct signs of
aortic injury. Periaortic hemorrhage identified at
the level of the diaphragm visible on abdominal
CT in a trauma patient should prompt CTA of the
chest (Fig. 5).62 Mediastinal hematoma without
direct signs of aortic injury was previously believed
to be an indication for aortography. However,
evidence now suggests that it is unnecessary
when mediastinal hematoma is encountered in
 Imaging of Aortic and Branch Vessel Trauma 91

Fig. 3. Aortic intimal tears not identified on catheter angiography. High-speed motor vehicle collision in a young
woman. (A) Catheter aortogram immediately following pelvic angioembolization was reported as negative for
aortic injury, but in retrospect a subtle intimal tear is visible (arrow). (B) Axial and (C) oblique sagittal volume
rendered images from a CT performed immediately after angiography reveal a circumferential intimal tear
(arrow) of the descending aorta. This tear is likely to be a stretch-type injury. The patient was treated with an
endovascular stent graft.

Fig. 4. Harborview Medical Center Screening algorithm for blunt thoracic aortic injury.
92 Gunn

Box 2 have acute angles with the adjacent aortic lumen,

CT signs of aortic injury
Periaortic hematoma (indirect)
End-organ arterial infarcts (indirect)
Aortic pseudoaneurysm
Active vascular extravasation
Intimal flap
Small intraluminal filling defects
Narrow aortic caliber
Periaortic hematoma at the diaphragm
Coarctation
Intramural hematoma
the absence of direct signs, especially if it can be
explained by the presence of other adjacent
injuries.49,63,64 End-organ infarcts, another indirect
sign, are occasionally seen (Fig. 6).
An aortic pseudoaneurysm is the most
commonly identified injury on CT. It is thought to
be caused by near complete transection of the
aortic wall, with sparing of the adventitia, or tam-
ponade due to hematoma.17 In most patients
who present to hospital the injury is at the level
of the aortic isthmus. Pseudoaneurysms fre-
quently occupy the inferomedial surface but they
can also be circumferential (Fig. 7). On axial
images, the pseudoaneurysm may resemble
a beret sitting on top of the aorta, which forms
the face (Fig. 8). Pseudoaneurysms typically
a feature that helps to distinguish them from duc-
tus diverticula. Active vascular extravasation
(Fig. 9) is rarely identified, and is thought to indi-
cate a poor outcome.49
Traumatic coarctation typically refers to
a small descending aorta distal to a large pseu-
doaneurysm. The mechanism for this has not
been determined, but compression by a proxi-
mally located pseudoaneurysm has been
suggested.51
Minimal Aortic Injury
Minimal aortic injuries comprise small (<10 mm)
intimal tears (grade I) and intramural hematomas
(grade II).4,34,65 These injuries have been increas-
ingly recognized as the use of CT screening has
increased. In an early helical CT series, they
were estimated to represent 10% of aortic
injuries.4 These injuries are likely to have been
underdiagnosed when catheter angiography was
the primary diagnostic test. Conservative man-
agement of minimal aortic injuries has been
examined in a few small series and is probably
effective and safe. Imaging surveillance is neces-
sary, especially for intimal tears greater than
10 mm.66,67
Minimal aortic injuries commonly appear as
small luminal filling defects, intimal flaps, and
intramural hematomas (Figs. 10 and 11). Serial
imaging may reveal resolution of the injury.
There should be no associated pseudoaneurysm,
and mediastinal hematoma is uncommonly
encountered.4

Fig. 5. Retrocrural periaortic hematoma on an upper abdominal CT image. (A) CT at the level of the diaphragm
reveals retrocrural blood (white arrow) and subadventitial blood around the descending thoracic aorta. (B) Ob-
lique sagittal thick-slab maximum-intensity projection shows the blood (white arrow) tracking around the aorta
and a large pseudoaneurysm at the level of the aortic isthmus (asterisk). The finding of unexplained retrocrural
blood on the upper cuts of a CT of the abdomen in the setting of trauma should prompt CTA of the chest.
 Imaging of Aortic and Branch Vessel Trauma 93

Fig. 6. Indirect signs of aortic injury. (A) Wedge-shaped bilateral renal infarcts (in addition to renal lacerations)
are present. No renal vascular injuries were noted on CTA. Note the perinephric hemorrhage. (B) Transection of
the isthmus of the aorta (asterisk) with unusually thick intimomedial flaps (likely with adherent thrombus) in the
same patient. Note the periaortic blood extending inferiorly around the aorta.

Fig. 7. Common appearances of traumatic pseudoaneurysms. (A) Volume-rendered projection (VR) of a CTA
showing a circumferential transection centered in aortic the isthmus (asterisk). (B) VR from a CT in another
patient showing a more localized pseudoaneurysm (asterisk). Note the acute angles on both the upper and lower
edges, a finding (along with periaortic hematoma) that helps differentiate from a ductus diverticulum. (C) Obli-
que sagittal thin-slab maximum-intensity projection revealing a transection with large intimomedial tears
extending into the aortic lumen (asterisk).
94

Fig. 8. Beret sign on axial CT. (A) Contrast-enhanced CT of the chest shows a pseudoaneurysm resembling a beret
cap (arrow) sitting on the head, formed by the aortic lumen (A). (B) Oblique sagittal reformat shows the level of
the corresponding axial slice (white line). The axial appearance has also been likened to a mushroom.

Fig. 9. Active vascular extravasation. (A) Axial CTA at the level of the aortic arch shows a large aortic traumatic
pseudoaneurysm (asterisk) surrounded by a large quantity of mediastinal blood. In addition, there was a right
hemothorax. (B) Oblique sagittal thin-slab maximum-intensity projection demonstrates active bleeding (arrow).
Unfortunately, the patient died soon after leaving the CT scanner.

Fig. 10. Minimal aortic injury. (A) Axial and (B) oblique sagittal images from a CTA showing a small filling defect
in the descending aorta (black arrow) resembling an intimal tear with adherent thrombus. The patient was
treated with b-blockers. A follow-up CTA 5 days later (not shown) revealed resolution of the filling defect.
 Imaging of Aortic and Branch Vessel Trauma 95

Fig. 11. Traumatic intramural hematoma of the aorta following a motor vehicle collision. (A) Axial CTA and (B)
oblique sagittal maximum-intensity projection reveal mural thickening of the descending aorta (white arrows).
(C) A noncontrast phase is not routinely performed to evaluate for aortic injury. However, in this patient the
lower slices of a noncontrast cervical spine CT revealed a hyperdense crescent of blood (gray arrow) correlating
with the mural thickening, confirming an intramural hematoma. The patient was treated conservatively.

Branch Vessel Injury particularly in the coronal and “candy-cane”

planes, are invaluable for the diagnosis of these
Although uncommon, injury to the aortic branch
injuries. Intimal flaps are also seen. Perivenous
vessels can be subtle, and should be specifically
artifacts from concentrated intravenous contrast
sought when there are fractures of the adjacent
in the subclavian and brachiocephalic veins may
thoracic cage or posterior sternoclavicular
obscure these injuries, so a right upper extremity
dislocation. No large series has evaluated the
injection is preferred.68
accuracy of CTA for the diagnosis of branch vessel
injury. As the branch vessels pass perpendicular to
Blunt Abdominal Aortic Injury
the plane of axial images, subtle changes in
vessel caliber due to pseudoaneurysms may be BAAI almost always occurs inferior to the
difficult to detect (Fig. 12). Multiplanar reformats, renal arteries, usually at the levels of the
96 Gunn

Fig. 12. Value of multiplanar imaging. (A) Axial CT in a patient with posterior right sternoclavicular fracture-
dislocation reveals perivascular blood surrounding the great vessels. The unusually large size of the brachioce-
phalic artery (BCA) (white arrow) is difficult to appreciate. (B) Oblique sagittal maximum-intensity projection
reveals 2 pseudoaneurysms of the BCA (black arrows). (C) On volume-rendered views a small pseudoaneurysm
of the origin of the right internal carotid artery (ICA) was identified (black arrow) in addition to the BCA pseu-
doaneurysms (white arrows). (D) Catheter angiogram reveals all 3 pseudoaneurysms (arrows).

inferior mesenteric artery or aortic bifurcation.30 Penetrating Aortic Injury

It is typically limited in length.28 Intimal disrupt-
Preoperative imaging is not commonly performed
ion, which may be circumferential, is the most
for patients with penetrating aortic and branch
commonly encountered finding on imaging
vessel injury, as these patients usually undergo
studies (Fig. 13). The distal intimal flaps may
immediate surgery. When imaging is performed,
be dissected or inverted by the blood flow
the findings include pseudoaneurysm, vascular
or may be a nidus for thrombus formation,
occlusion, active contrast extravasation, and
leading to arterial insufficiency.30 Pseudoaneur-
intimal flaps (Fig. 14).69 In cases of gunshot injury,
ysms, true rupture, and thrombosis may also
the patient should always be surveyed for the
occur.
presence of an exit wound as well as vascular
embolization of projectiles (Fig. 15).
 Imaging of Aortic and Branch Vessel Trauma 97

Fig. 13. Blunt abdominal aortic injuries (BAAI) from high-speed motor vehicle collisions. (A) Sagittal and (B)
coronal images from a CTA of the abdomen reveal a stretch-type injury to the infrarenal abdominal aorta. The prox-
imal and distal intimal flaps are visible, and there is a small intervening aortic pseudoaneurysm. (C) Axial CTA in
a different patient reveals a circumferential intimal tear just above the bifurcation, not an unusual finding in BAAI.

Fig. 14. Penetrating abdominal aortic injury. A young man who was shot in the anterior abdomen. (A) Axial and
(B) sagittal images from a CTA following laparotomy for repair of injuries to the bowel and mesentery reveal pseu-
doaneurysms arising from the posterior (arrows) and anterior (arrowhead) surfaces of the abdominal aorta. The
bullet is in the paraspinal muscles. Following open repair of the pseudoaneurysm, the man made a good recovery.
98 Gunn

Fig. 15. Penetrating aortic injury with bullet embolization in a young man shot in the back. No exit wound was
found. (A) Axial CTA following emergent thoracotomy reveals the bullet course (dotted line) through the left
atrium (LA) and noncoronary sinus of the aorta [shown as (A)]. A pseudoaneurysm is visible between the aorta
and coronary sinus (arrow). The bullet entered at a lower level (not shown) and traveled cranially, hence the injured
vertebral body injury is not shown. (B) A CT scout image reveals a metallic body in the left groin (arrow). (C) CTA of
the pelvis performed in combination with the chest CTA demonstrates the bullet lodged in the common femoral
artery bifurcation (arrow) with adherent thrombus. The patient received aortic and groin surgery and survived.

PITFALLS IN THE INTERPRETATION OF AORTIC
INJURY ON MDCT
Aortic Arch Variants: Ductus Diverticulum,
Aortic Spindle, Branch Infundibula, and
Physiologic Shape Variation
Ductus diverticulum (DD) is a common develop-
mental outpouching of the thoracic aorta, present
in 33% of newborns and between 9% and 26% of
normal adults.58,70 The DD is usually located on
the anteromedial aspect of the aortic isthmus at
the site of the ligamentum arteriosum, the remnant
of the fetal ductus arteriosum. Some propose that,
it might be a remnant of the right dorsal aortic
root.71 Unfortunately, this is also by far the most
common site of BTAI. Although a DD typically
has smooth obtuse angles at its junction with the
normal aortic wall, in a minority of cases a DD
may form an acute angle at its superior margin. If
the obtuse angles are not present, the best means
of excluding injury are noting the absence of peri-
aortic hematoma adjacent to the DD (Fig. 16A).
Penetrating atherosclerotic ulcers, which may
also occur in a similar location, can also simulate
a traumatic pseudoaneurysm.
 Imaging of Aortic and Branch Vessel Trauma 99

Fig. 16. (A) Thin-slab maximum-intensity projection demonstrating a small ductus diverticulum (arrow). Note the
gentle angles with the aortic arch and the slightly more acute angle at the superior margin, a common finding.
(B) Aortic spindle deformity with widening of the aorta immediately beyond the isthmus (double-headed arrow).
(C) Bronchial artery infundibulum. Axial CTA shows a small outpouching of the aorta in the region of the isthmus
(arrow), which on thin-slab sagittal maximum-intensity projection (D) is shown to connect to a bronchial artery
(arrow).

The aortic spindle is a fusiform dilation of the
aorta immediately beyond the aortic isthmus that
is present in the fetal aorta. This spindle may
persist into adulthood and mimic a circumferential
aortic pseudoaneurysm (Fig. 16B).72
Branch vessel infundibula are occasionally seen
at the origin of bronchial and intercostal arteries,
and may simulate small pseudoaneurysms as
they project beyond the expected contour of the
aortic lumen. Close inspection of the infundibulum
will reveal smooth margins, and a vessel origi-
nating from the apex (Fig. 16C, D).
Recent work has demonstrated considerable
physiologic variation in the diameter, shape, and
length of the normal thoracic aorta during the
cardiac cycle, especially in younger patients who
have more elastic vessel walls.73,74 In one series,
a change in maximum aortic diameter of 12% to
17% was observed in the aorta distal to the left
subclavian artery.75 During nongated aortic CTA,
these changes in aortic contour and size can
mimic aortic injury. Smooth variation in the shape
of the thoracic aorta in young patients should not
be misinterpreted as a sign of aortic injury.
100 Gunn

Fig. 17. Pulsation artifact. (A) Axial and (B) sagittal images from a chest CT in a patient stabbed in the chest reveal
a double contour to the aortic arch (white arrows). A double contour to the sternum (arrowhead) is also visible,
indicating motion artifact. Motion artifact can arise from voluntary movement, breathing, vascular pulsation, or
cardiac motion. Adjacent vessels (eg, the pulmonary artery), bones, and tubes should always be examined for
similar artifacts to confidently exclude an aortic injury.

Pulsation Artifact REFERENCES

Pulsation artifacts most commonly occur in the
ascending aorta and aortic root, although they
can be identified throughout the length of the
thoracic aorta. Ninety-two percent of aortic
motion artifacts are simultaneously seen in the
left anterior and right posterior quadrants of the
aorta. In 93% of cases, motion artifact can also
be demonstrated in the superior vena cava
(SVC), with a “pseudointimal” flap.73,76 An impor-
tant discriminatory clue to the presence of
a motion artifact is the observation of similar arti-
facts in adjacent structures. Whenever a motion
artifact is suspected, the SVC, pulmonary artery,
adjacent tubes and lines, and bones should be in-
spected for concurrent artifacts at the same level
(Fig. 17). Concurrent traumatic injuries to the
pulmonary artery and SVC at the same level
almost never occur.
SUMMARY
Liberal use of multidetector-row CTA will allow
for the accurate diagnosis of aortic and branch
vessel injury in almost all cases, and provides
a baseline for endovascular repair and surgical
planning. Greater integration of rapid CT into
the evaluation of the severely injured patients,
and the evolving use of DSCT and ECG-gated
CTA for the evaluation of more subtle and
challenging injuries, provide opportunities for
further improvement in the evaluation of aortic
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